BENZO TRAP
far higher doses than they would
have obtained on the NHS. These
same patients, when presenting to
GPs for treatment, may encounter
the same reluctance to prescribe
benzos that pushed them to the
street market in the first place.
PRESCRIBING TRAP
The NICE BNF guidance on benzos
for the treatment of anxiety allows
for doses up to 30mg a day. For
someone who has a significant
street-acquired strong benzo habit,
the BNF upper limit may be well
below that person’s current dose.
The dose equivalence for someone
using four 2mg alprazolam a
day (8mg x 20) would be 160mg
diazepam – more than five times the
BNF upper limit for treating anxiety.
Where services do have a
benzo-prescribing pathway it
typically requires a person to
reduce themselves off their own
illicit benzos to a level where
drug services or GPs could take
over prescribing. This approach
effectively directs a person to
continue purchasing off the illicit
market, with all the risks that
this entails. It is the equivalent of
having an arbitrary maximum dose
of 30ml methadone and saying to
heroin users they should reduce
themselves off street heroin until
they get to this level.
This situation also assumes that
the person has continued access to
illicit benzos that they can taper off.
If a person has been purchasing off
a dark web site which is then shut
down, they could be left without
any access to drugs, withdrawing
off a high dose with no access to
legal substitutes. This brings with it
huge risks, including psychosis and
life-threatening convulsions.
ASHTON MANUAL
Many professionals and people
seeking help online will find the
Ashton Manual, a guide to benzo
reduction and withdrawal by
Professor C Heather Ashton. A
helpful resource for many, the
manual and related resources
create two key challenges. First, for
some people, reading the manual
could reinforce fear and anxiety
of withdrawal symptoms. There
is a risk that people will anticipate
and expect symptoms and could
therefore experience a wider range of
symptoms and with greater severity.
Second, the withdrawal
schedules suggested by Ashton
typically reflect people reducing off
NHS-prescribed dose ranges. Where
people have built up dependency
on stronger novel benzos, and built
up high tolerance on street drugs,
following the sort of slow tapers
proposed by Ashton could take one
to two years or longer to complete.
While on the one hand very slow
tapers as described by Ashton
minimise risks of unpleasant
or dangerous symptoms, they
can prove prohibitively and
unnecessarily slow for people who
have been using at high doses.
Minute dose reductions can lead to
people fixating on each reduction,
and losing motivation over a
protracted reduction programme.
UNKNOWN TABLETS
Efforts to accurately substitute
prescribe for illicitly acquired benzo
habits are further confounded by
our uncertainty as to the specific
drug and specific dose that the
person is actually taking.
A significant amount of the
tablets sold as Xanax could contain
one or more other compounds.
Alprazolam may or may not be
present – weaker or stronger
benzos could be present, and these
could be shorter or longer acting
than alprazolam. Dose may be
higher or lower than the claimed
strength, and there may be other
psychoactive compounds present
such as quetiapine.
While drug testing websites
such as WEDINOS are invaluable
in highlighting trends in pill
composition they are less helpful
when considering tapers and
withdrawal protocols – even if pills
held by the client are submitted for
analysis. The analysis doesn’t show
the amount of each psychoactive
compound in a pill, and without
testing several pills from a batch,
Escaping the trap
no certainty can be derived from
testing a single pill.
This uncertainty about drug,
dose and strength makes it
impossible to accurately assess:
• what level of substitute
prescribing is required
• how fast or slow a taper should
be applied – some novel benzos
have a very long duration of
effect (100-200 hours) and so
slower tapers may be required.
In lieu of accurate and rapid pill
testing, the only practical way of
substitute prescribing and tapering
is to prescribe symptomatically,
increasing dose and slowing
withdrawal where there are clinical
indicators of unmanageable
withdrawal symptoms combined
with careful assessment of the
patient’s self-reported symptoms.
Kevin Flemen runs the drugs
education and training initiative KFx
– www.kfx.org.uk
Workshops have moved online
during the current lockdown.
Email [email protected] for joining
instructions.
Services need to urgently develop new pathways and
treatment protocols for people using benzodiazepines
outside of clinical and prescribed settings. These need to
include:
• screening tools to assess for patterns and nature of
benzo use
• research into the extent of non-prescribed benzo use
in the UK
• protocols to test clients’ pills for content and potency
• appropriate levels of substitute prescribing with tapers
• rapid access for children experiencing anxiety to
CAMHS to reduce self-medicating with benzos
• staff training and training for GPs about addressing
the use of prescribed benzos without driving people
towards illicit markets.
Photo: ajt/iStock
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